Chapter 9
Reflexes
This chapter is devoted to the reflexes observed in infants and children that therapy interventions may be directed toward integration of at the appropriate stages. Reflexes may be one factor that is investigated by therapists in infants and children referred for treatment interventions. THE ROOTING REACTION
Onset - 28 weeks gestation Integration - 3 months Testing position - with the infant supine, the head in midline and hands on chest Procedure - gently stroke the infant from the lips to the cheek Normal response - the infant should turn his head toward the stimulated side with the mouth opening and a trial of sucking the finger. May not be present if the infant is not hungry. Functional significance - persistence can interfere with sucking. Absence of this is seen in neurologically impaired infants.
THE SUCK SWALLOW REFLEX
Onset - begins at 28 weeks gestation Integration - 2-5 months Testing position - infant supine with the head in midline Procedure - place a finger of nipple into the infants mouth Response observed - rhythmical sucking Functional significance - persistence of this reflex may inhibit voluntary sucking
MORO
Onset - begins at 28 weeks gestation Integration - 5-6 months Testing position - child in supine with head in midline, support the child's head while pulling the child to a position halfway between supine and upright sitting Procedure - support the infants head and shoulders with one hand. Allow the neck to drop back to allow the anterior neck muscles to stretch Response observed - the shoulders abduct, the elbows, wrists and fingers extend. Subsequently, the shoulders adduct, and the elbows and fingers flex Functional significance - asymmetry during this reaction may indicate a brain lesion or injury or peripheral nerve problems to the upper extremity
THE TRACTION RESPONSE
Onset - begins at 28 weeks gestation Integration - 2-5 months
Testing position - child in supine with the arms and head in midline Procedure - grasp the childs wrists and pull up to sitting placing a stretch on the shoulder adductors and arm flexors Response observed - the child will flex and elevate shoulders, arms and wrists Functional significance- traction is a primitive reflex which enables the child to hold onto the mother when being pulled. Traction helps stabilize the head before the child has voluntary head control
CROSSED EXTENTION
Onset - begins at 28 weeks gestation Integration - 1-2 month Testing position - child in supine, head in midline, lower extremities extended Procedure - Holding one leg in extension at the knee, apply firm pressure to the sole of this leg Response observed - childs opposite leg will flex, adduct, and then extend Functional significance - this reflex can interfere with reciprocal kicking and later functional activities
FLEXOR WITHDRAWAL
Onset - begins at 28 weeks gestation Integration - 2 months for normal child; may persist in developmentally delayed and/or CP child Testing position - child supine, head midline, lower extremities extended Procedure - apply a noxious stimulus to the sole of the foot Response observed - withdrawal of the foot from the stimulus employing hip and knee flexion Developmental significance - failure to attain and integrate this reflex may indicate sensorimotor delay and/or CNS depression
PLANTAR GRASP
Onset - begins at 28 weeks gestation Integration - 9 months Testing position - child supine, head midline, legs relaxed Procedure - apply firm pressure to the plantar surface of the childs foot Response observed - plantar flexion of all of the toes Functional significance - this reflex is referred to as the "readiness tester". Integrates at the same time that independent gait first becomes possible.
GALANTS RESPONSE
Onset - begins at 32 weeks gestation Integration - 2 months, though may persist in atypical children Testing position - infant placed prone in alignment
Procedure - gently stimulate along the paravertebral area from the C7 area to the buttocks Response observed - infant will laterally flex toward the stimulated side Functional significance - often seen with children with athetoid CP
NECK RIGHTING ON THE BODY (NOB)
Onset - begins at 34 weeks gestation Integration - 4-6 months Testing position - infant in supine, head midline Procedure - turn the infants head to one side Response observed - infants entire body will turn in the direction of the head Functional significance - early in development the infant uses NOB in order to transition between supine, sidelying, and eventually prone
BODY RIGHTING REACTION (BOB)
Onset - begins at 34 weeks gestation Integration - 4-5 months Testing position - infant supine, head midline Procedure - flex one limb over the chest and rotate the limb across the body Response observed - infants upper body will follow the pelvis in a log roll Functional significance - this reflex assists the child in rolling between supine and prone
NEONATAL POSITIVE SUPPORTING IN THE LOWER EXTREMITIES
Onset - begins at 35 weeks gestation Integration - 1-2 months Testing position - support the infant in a vertical position Procedure - allow the feet to make firm contact with the floor or table Response observed - simultaneous contraction of the babys flexor and extensor muscles of the lower extremities supporting only minimal weight with the hips and knees remaining in partial flexion Functional significance - prerequisite for the spontaneous stepping reflex
PROPIOCEPTIVE PLACE OF LOWER EXTREMITY
Onset - begins at 35 weeks gestation Integration - 2 months Testing position - supported in a vertical position Procedure - lift the infant so that the dorsum of the foot presses against the edge of the table Response observed - the infant flexes his knee and hip, thereby lifting the foot above the table Functional significance - asymmetry may indicate a CNS injury, muscles weakness, or peripheral nerve damage
SPONTANEOUS STEPPING
Onset - begins at 37 weeks gestation Integration - 2 months Testing position supported in the vertical position Procedure - support the infant upright with the feet touching a hard surface. Incline the infant forward and gently move the infant forward to accompany any stepping Response observed - alternating, rhythmical, and coordinated steps Functional significance - premature infants will tend to walk in a roe-heel fashion while more mature infants will walk in a heel-toe pattern.
PALMAR GRASP
Onset - 10 weeks gestation Integration - 4-6 months Testing position - supine, head midline, arms and hands free Procedure - place a finger in infants hand from the ulnar to the palmar surface Response observed - infants fingers will flex around the finger Functional significance -following the development of grasp, the infant begins to reach for objects and utilizes a crude palmer grasp to hold them
UPPER EXTREMITY PROPRIOCEPTIVE PLACING
Onset - birth Integration - 2 months Testing position - support the infant in a vertical position Procedure - move the infant so that the dorsum of one hand rubs against a hard surface Response observed - the upper extremity flexes and the hand is brought above the surface of the surface Functional significance - this reflex may be obtained at any age as a withdrawal response if excessive pressure is applied to the hand
ASSYMETRICAL TONIC NECK REFLEX (ATNR)
Onset - 0-2 months Integration - 4-6 months Testing position - supine Procedure - gently turn the infants head to one side Response observed - a UE flexion tone on the side opposite to the head turn with an increase in UE extensor tone in the side to which the head is turned Functional significance - persistence of this reflex may indicate CNS damage
TONIC LABYRINTHINE REFLEX (TLR)
Onset - birth Integration - 6 months
Testing position - prone or supine Procedure - prone - lift the infant up to evaluate for the presence of flexor tone; supine, lift the child to sitting to observe for extensor tone Response observed - prone - flexor tone will dominate; supine - extensor tone Functional significance - persistence of TLR will impede activities which require graded coactivation of flexor and extensor muscles
ASSOCIATED REACTIONS
Onset - birth to 3 months Integration - never, less common after 8-9 years Testing position - sitting Procedure - hand grasp in younger children, rapid arm movements in older children Response observed - overflow of movement to the contralateral side should decrease with age Functional significance - excessive build-up of movement, or tonal increases in the opposite extremity indicate brain damage
LABYRINTHINE HEAD RIGHTING
Onset - birth to 2 months Integration - persists throughout life Testing position - vertical position Procedure - tilt the child anterior, posterior, and lateral from the vertical Response observed - the head orients to the vertical position and is maintained steady Functional significance - in order to move around in space, this reflex is necessary to allow the body to turn freely around the head
OPTICAL RIGHTING
Onset - birth to 2 months Integration - persists through life Testing position - vertical position Procedure - tile the child anterior, posterior, and lateral from the vertical Response observed - the head orients to the vertical position and is maintained vertically oriented in the environment Functional significance - allows the head and body to be upright to the horizon
BODY RIGHTING REACTION ON THE HEAD (BOH)
Onset - birth to 2 months Integration - persists through life Testing position - upright Procedure - observe during play Response observed - righting of the head in relation to the body
Functional significance - important in controlling the head in relation to the body in all positions
LANDAU
Onset - 3 -4 months Integration - 12 - 24 months Testing position - prone, supported in air Procedure - wait for a reaction after placement Response observed - the head will extend and the back and hips will extend in sequence ("superman" appearance) Functional significance - breaks up the total flexion pattern seen at birth
UPPER EXTREMITY POSITIVE SUPPORT
Onset - on elbows at 3 months Integration - persists through life Testing position - prone Procedure - keep infant horizontal and rise slowly up so that the upper extremities contact the floor Response observed - simultaneous contraction of the UE flexors and extensors leading to full weight bearing on hands Functional significance -allows for sitting and standing positions to be attained
UPPER EXTREMITY VISUAL PLACING
Onset - 3 - 4 months Integration - persists through life Testing position - vertically held under the arms Procedure - advance the infant toward a supporting surface Response observed - the infant will lift both UE, extend and then place them on the supporting surface with fingers abducted and extended Functional significance - asymmetry may indicate hemispheric insult, peripheral nerve damage, or muscle weakness
LOWER EXTEMITY VISUAL PLACING
Onset - 3 - 5 months Integration - persists through life Testing position - infant held vertically in space Procedure - advance the infant slowly toward a supporting surface feet first Response observed - the infant will orient to the surface and place both feet on top of the supporting surface Functional significance - needed for independent ambulation
PROTECTIVE EXTENSION DOWNWARD
Onset - 4 months Integration - persists through life Testing position - vertically suspended in air Procedure - plunge the infant downward Response observed - the legs externally rotate and abduct with the feet dorsiflexing in preparation for weight-bearing Functional significance - preparation for standing and breaks a fall
POSTURAL FIXATION IN PRONE
Onset - 6 months Integration - persists through life Testing position - prone Procedure - encourage the child to support on one extremity while reaching for an object Response observed - the child will not loose balance when reaching Functional significance - postural fixation is necessary for the preservation of the center of gravity in prone
TILTING REACTION IN PRONE
Onset - 6 months Integration - persists through life Testing position - prone on a tilt board Procedure - slowly tile the board and wait for a response Response observed - the child will curve his trunk against the displacement the center of gravity. The upper arm and leg may abduct Functional significance - part of the balance mechanism to tolerate perturbations
PROTECTIVE EXTENSION FORWAD
Onset - 6-7 months Integration - persists through life Testing position - vertically supported Procedure - plunge the child downward head first Response observed - the child should extend and abduct the arms with the fingers extended and spread as if to break a fall Functional significance - necessary for prop sitting
SYMMETRICAL TONIC NECK REFLEX (STNR)
Onset - 4-6 months Integration - 8 - 12 months Testing position - child in quadruped position on the floor Procedure - passively flex the head forward and then extend it backwards
Response observed - forward head flexion will produce flexion of the upper extremities and extension of the lower extremities; extension of the head will produce extension of the upper extremities and flexion of the lower extremities Functional significance - necessary to achieve quadruped crawling
POSITIVE SUPPORT WEIGHT BEARING ON LOWER EXTREMITIES
Onset - 6-9 months Integration - persists through life Testing position - vertically positioned Procedure - allow the infants feet to make firm contact with a flat surface Response observed - simultaneous contraction of the lower extremity flexors and extensors bilaterally Functional significance -needed for upright standing and walking
MATURE NECK RIGHTING ACTING ON THE BODY (NOB)
Onset - 4-6 months Integration - 5 years Testing position - supine Procedure - flex the childs head and slowly turn to one side; hold this position and observe, repeat on the opposite side Response observed - child will segmentally roll in the direction of the head rotation Functional significance - allows for mature rolling and gait rotation
MATURE BODY RIGHTING REACTION ACTING ON THE BODY (BOB)
Onset - 4-6 months Integration - 5 years Testing position - supine with head in midline Procedure - flex one leg and rotate it across the pelvis to the opposite side Response observed - child will roll sideways segmentally Functional significance - working with NOB, promotes segmental rolling and is important for sitting, quadruped and standing positions
PROTECTIVE EXTENSION SIDEWARD OF THE UPPER EXTREMITY
Onset - 7 months Integration - persists through life Testing position - long sitting position Procedure - apply a force to the shoulder to displace the center of gravity Response observed - the arms should abduct and extend of the side toward the fall with weight borne on the open palm and fingers Functional significance -needed for independent sitting
POSTURAL FIXATION IN SUPINE
Onset - 7 - 8 months Integration - persists through life Testing position - supine Procedure - encourage the child to reach, exert a minimal force on the shoulder of the reaching arm Response observed - the child will loose his balance in response to the push and demonstrate a slight curving of the spine Functional significance - necessary for the preservation of the center of gravity in supine
POSTURAL FIXATION IN SITTING
Onset - 7 - 8 months Integration - persists through life Testing position - sitting on a stool Procedure - encourage the child to reach while exerting a minimal force to the opposite shoulder or trunk Response observed - will not lose balance Functional significance -necessary for preservation of sitting balance
TILTING REACTION IN SUPINE
Onset - 7 - 8 months Integration - persists through life Testing position - supine on a tilt board Procedure - slowly tile the board laterally, wait for a response, and tilt to the opposite side Response observed - childs trunk will curve against the tile with the concavity of the spine upward; the head will rotate for the face to look toward the upper side of the board Functional significance -allows for maintenance of the body while fine motor tasks are being undertaken; indicates the presence of previous righting reactions
POSTURAL FIXATION IN QUADRAPED
Onset - 9 - 12 months Integration - persists through life Testing position - place the child in a quadruped on the floor Procedure - apply force to the shoulder and observe; to the extremity and observe; contralateral leg and observe; and ipsilateral leg and arm and observe Response observed - observe rotation of the body in the plane of the applied force Functional significance - necessary for the preservation of the quadruped position
PROTECTIVE EXTENSION BACKWARD
Onset - 9 - 10 months Integration - persists through life Testing position - symmetrical sitting posture with legs extended Procedure - push the child backward with enough force to displace the center of gravity
Response observed - the child will extend the arms backward Functional significance - necessary for independent sitting
PROTECTIVE STAGGERING OF LOWER EXTREMITIES
Onset - 15 - 18 months Integration - persists through life Testing position - standing Procedure - push the child in all directions Response observed - the child will make corrective movements in order to restore center of gravity Functional significance - protects the upright posture
POSTURAL FIXATION IN STANDING
Onset - 12 - 21 months Integration - persists through life Testing position - standing and one-legged standing Procedure - exert minimal force to the pelvis in all four directions Response observed - observe for force fields of the lower extremities to prevent falling or tipping Functional significance - allows for the preservation of the center of gravity and balance in standing and walking
TILTING REACTION IN STANDING
Onset - 12 - 21 months Integration - persists through life Testing position - standing on a tilt board Procedure - tilt and wait for response, repeat the opposite direction Response observed - the body should flex against the tilt with the upper leg flexed and arm abducted while the lower leg is extended and braced Functional significance - the inner ear labyrinths need to be intact in order for the reaction to occur
This chapter presented many of the reflexes seen at birth through life. It is meant as a highlight of the most common types the therapist should be aware of and test for when presented with an infant or child with possible developmental delay or tonal problems. Reflex testing can assist the therapist in determining the cause of the delay such as CNS impairment, peripheral nerve injury, and muscle weakness. Reflex review will also assist in developing an individual treatment intervention designed to help the child integrate reflexes that appear to be delayed or missing.